EBM Karen Estrella PGY-3 10/14/2011

Rhadomyolysis Rhabdomyolysis means destruction of striated muscle –Characterized by muscle breakdown and necrosis resulting in the leakage of the intracellular muscle constituents into the circulation and extracellular fluid –Asymptomatic with elevation of CPK to a life-threatening condition, associated with extreme high levels of CPK, electrolyte imbalances, ARF and DIC. hyperkalemia, hypocalcemia, hyperphosphatemia and hyperuricemia, elevation of lactate dehydrogenase, aldolase, aminotransferases and carbonic anhydrase III ARF: related to hypovolemia/dehydration and aciduria. –Heme-induced RF: renal vasoconstriction with diminished renal circulation, intraluminal cast formation and direct heme protein-induced cytotoxicity.

PICO Population: pts with rhabdomyolysis Intervention: Hydration therapy Comparison: NS vs adding NaHCO3 Outcome: prevention of hem-induced renal failure

Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference? Brown CV, Rhee P, Chan L, Evans K, Demetriades D, Velmahos GC. Department of Surgery, Division of Trauma and Critical Care, University of Southern California and the Los Angeles County Medical Center, Los Angeles, California, USA J Trauma Jun;56(6): Objective: determine whether bicarbonate/ mannitol is effective in preventing RF in patients with rhabdomyolysis caused by trauma. Methods: Chart review of all adult trauma ICU admissions from 01/1997 to 09/2002 Results: total: 2083=85% with abnormal CPK levels –CPK >5000: 382===74 (19%) RF No difference in the rates of RF, dyalisis, or mortality between those who received BIC/MAN and those who did not. –CPK< 5000: 1701=== 143 (8%) Conclusion: a CPK >5,000 U/L is associated with RF and the use of BIC/Man does not prevent RF, dialysis The standard of administering BIC/MAN to patients with post-traumatic rhabdomyolysis should be reevaluated.

Prophylaxis of acute renal failure in patients with rhabdomyolysis. Homsi E, Barreiro MF, Orlando JM, Higa ICU, Hospital Municipal Artur de Saboya, Sao Paulo, Brazil Ren Fail Mar;19(2): Objective: Assess the therapeutic response to prophylactic treatment in pts with rhabdomyolysis. Methods: retrospective study, ICU pts: 1/92-1/95 –CPK > 5000, creat <3, admitted to ICU in <48hrs Results: 36===24 1. NS, ½ NS alone: NS, 1/2NS + mannitol+bicarbonate: 9 >>IVF 200ml/hr, UO: 100ml/hr, during initial 60hrs, with similar decrease in creatinine values Conclusion: “Progression to established renal failure can be totally avoided by prophylactic treatment, and that once saline expansion is provided, the association of mannitol+bicarbonate seems to be unnecessary”

Early and Vigorous Fluid Resuscitation Prevents Acute Renal Failure in the Crush Victims of Catastrophic Earthquakes Ali Ihsan Gunal*, Huseyin Celiker*, Ayhan Dogukan*, Goksel Ozalp*, Ercan Kirciman*, Huseyin Simsekli*, Izzettin Gunay*, Mustafa Demircin*, Oktay Belhan†, Mustafa A. Yildirim‡ and Mehmet S. Sever Istambul University, Turkey Objective: To analyze the effects of fluid resuscitation in the crush victims of the Bingol earthquake, which occurred in May 2003 in southeastern Turkey. Methods: Questionnaires asking about demographic, clinical, laboratory, and therapeutic features of 16 crush victims were filled in retrospectively. Mean duration under the rubble was 10.3 ± 7 h, and all patients had severe rhabdomyolysis. Fourteen patients were receiving isotonic saline at admission, which was followed by mannitol-alkaline fluid resuscitation. All but two patients were polyuric. Admission serum creatinine level was lower than and higher than 1.5 mg/dl in 11 and 5 patients, respectively. Marked elevations were noted in muscle enzymes in all patients. During the clinical course, hypokalemia was observed in nine patients, all of whom needed energetic potassium chloride replacement. Four (25%) of 16 victims required hemodialysis. Duration between rescue and initiation of fluids was significantly longer in the dialyzed victims as compared with nondialyzed ones (9.3 ± 1.7 versus 3.7 ± 3.3 h, P < 0.03). Sixteen fasciotomies were performed in 11 patients (68%), nine of which were complicated by wound infections. All patients survived and were discharged from the hospital with good renal function. Conclusions: Early and vigorous fluid resuscitation followed by mannitol-alkaline diuresis prevents acute renal failure in crush victims, resulting in a more favorable outcome.

Comparison of lactated Ringer's solution and 0.9% saline in the treatment of rhabdomyolysis induced by doxylamine intoxication. Cho YS, Lim H, Kim SH. Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Seoul, Korea EMERG MED J 2007;24: Objective: To compare the effectiveness and side effects of LR and 0.9% NS in the treatment of rhabdomyolysis induced by doxylamine intoxication. Methods: prospective study: single blind for 15months. –Total: 97 pts with doxylamine intoxication 28 (31%) rhadomyolysis 1.LR group: 13 2.NS group 15 Results: after 12 hrs of aggressive hydration (400ml/hr) –No significant differences in serum K+ level (p=0.125) and in the time taken for CPK normalization (p=0.058) –LR group less metabolic acidosis, higher urine/serum pH –NS group: serum Na+/Cl- levels to be significantly higher Conclusion: LR is more useful than NS in the treatment of rhabdomyolysis induced by doxylamine intoxication.

For urine alkalisation, only 2 from 15 patients in the LR group received sodium bicarbonate, 40 and 60 mEq, respectively. In contrast, all 13 patients of the NS group received 140 (100–700) mEq of sodium bicarbonate for urine alkalisation (p<0.001). The median number of diuretic administrations was 1 (1–2) in the LR group and 3 (3–4) in the NS group (p=0.001).